Impact of Let’s Go! 5-2-1-0: A Community-Based, Multisetting
Childhood Obesity Prevention Program
Victoria W. Rogers,1 MD, Patricia H. Hart,2 MS, Elizabeth Motyka,1 MPH, Emily N. Rines,3 MPH,
MCHES, Jackie Vine,1 MS, and Deborah A. Deatrick,4 MPH
1
The Barbara Bush Children’s Hospital at Maine Medical Center, 2Hart Consulting, Inc., Gardiner, Maine,
3
United Way of Greater Portland, Portland, Maine, and 4MaineHealth, Portland, Maine
All correspondence concerning this article should be addressed to Victoria W. Rogers, MD, Director,
Let’s Go!, The Barbara Bush Children’s Hospital at Maine Medical Center, 22 Bramhall Street, Portland,
ME 04102, USA. E-mail: [email protected]
Received September 26, 2012; revisions received May 3, 2013; accepted June 27, 2013
Objective Document the impact of Let’s Go!, a multisetting community-based childhood obesity prevention
program on participants in 12 communities in Maine. Methods The study used repeated random telephone surveys with 800 parents of children to measure awareness of messages and child behaviors. Surveys
were conducted in schools, child care programs, and afterschool programs to track changes in policies and
environments. Results Findings show improvements from 2007 to 2011: Children consuming fruits and
vegetables increased from 18%, 95% CI [15, 21], to 26% [23, 30] (p < .001); children limiting sugary drinks
increased from 63% [59, 67] to 69% [65, 73] (p ¼ .011); and parent awareness of the program grew from
10% [7, 12] to 47% [43, 51] (p < .001). Participating sites implemented widespread changes to promote
healthy behaviors. Conclusions A multisetting, community-based intervention with a consistent message
can positively impact behaviors that lead to childhood obesity.
Key words
health education; health promotion and prevention; obesity; public health.
The obesity epidemic is widely acknowledged as one of the
greatest public health challenges in the United States for
children (Stroup, Johnson, Hahn, & Proctor, 2009). Over
the past 30 years, obesity rates among children and adolescents aged 2–19 increased nearly threefold from 6 to
17% (Fryar, Carroll, & Ogden, 2012). Obesity now affects
more than one in six children in the United States. The
situation is similar in Maine, with a 2011 youth health
surveillance study recording 23% of kindergarten students,
and 24% of fifth grade as obese. Adding those students
who were also overweight, Maine’s study showed 38%
of students in kindergarten, and 44% of students in fifth
grade were either overweight or obese (Maine Department
of Health and Human Services & Maine Department of
Education, 2011).
The effects of being overweight are acute among children. Overweight and obese children are much more likely
than their healthy weight peers to become obese adults,
(Freedman et al., 2005; Guo et al., 2000; Singh, Mulder,
Twisk, Van Mechelen, & Chinapaw, 2008), and they face
increased risks for many chronic health and mental health
conditions (Bray, 2004; Dietz, 1998; Freedman, Dietz,
Srinivasan, & Berenson, 1999; Loth, Mond, Wall, &
Neumark-Sztainer, 2011; Must, Jacques, Dallal, Bajema,
& Dietz, 1992).
The dramatic rise in obesity over the past three decades occurred at the same time as major environmental,
social, and lifestyle changes. These days, Americans consume more fast foods and sugary drinks than ever before;
processed foods are low-cost and readily available; and
people engage in more sedentary leisure time activities
such as viewing television or using electronic devices
(Hill, Wyatt, Reed, & Peters, 2003). Overweight is a
result of a calorie imbalance, genetics, and health status
Journal of Pediatric Psychology 38(9) pp. 1010–1020, 2013
doi:10.1093/jpepsy/jst057
Advance Access publication August 11, 2013
Journal of Pediatric Psychology vol. 38 no. 9 ß The Author 2013. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: [email protected]
Impact of Let’s Go! 5-2-1-0
that can be impacted by improving diet, increasing physical
activity, and reducing sedentary activity (Berkey et al.,
2000; Swinburn, Caterson, Seidell, & James, 2004). Like
some other chronic health conditions, with focus and
effort, obesity and overweight can be reduced and even
prevented.
In 2006, concerned about the health and economic
impacts of childhood obesity in Maine, the United Way of
Greater Portland convened six of the region’s largest employers to launch Let’s Go!, a community-based approach
to improve the underlying health behaviors that have been
demonstrated to impact overweight and obesity: Healthy
eating and physical activity (American Academy of
Pediatrics, 2003; Berkey et al., 2000; Must, Barish, &
Bandini, 2009; Swinburn, Caterson, Seidell, & James,
2004). The initial program was operated as a five-year demonstration project in 12 contiguous municipalities, including Portland, Maine’s largest city, with plans to spread the
work to other parts of the rural state.
The Let’s Go! model design had two major components: Deploying a simple consistent message, 5-2-1-0,
across multiple community settings to remind families
and children how to make healthy choices, and implementing changes to environments as well as policies that support the healthy choices in six settings where families live,
learn, work, and play. The mnemonic, 5-2-1-0, represents
four recommendations for healthy eating and physical activity each day: ‘‘eat five or more servings of fruits and
vegetables,’’ ‘‘limit of two hours or less of recreational
screen time,’’ ‘‘engage in one hour or more of physical
activity,’’ and ‘‘limit sugary drinks; drink more water and
low fat milk’’ (Rogers & Motyka, 2009). The six settings
included schools, child care programs, afterschool programs, health care practices, worksites, and community
sites. The multisetting approach follows the social ecological model that has guided many public health interventions to promote sustainable behavior change (Stokols,
1996). The model recognizes the complex set of influences
on a person’s behaviors, such as family customs, local culture, supporting environments, and policies in the places
where people spend time such as at school, work, and
recreation sites.
The primary goal of this study was to evaluate the Let’s
Go! program hypothesis that by exposing families and children to a consistent health message in multiple settings,
and by changing influential environments to support
healthy choices, the awareness, knowledge, and practice
of the healthy behaviors will increase. The Centers for
Disease Control and Prevention (CDC) implemented a
similar comprehensive social marketing campaign to promote the single behavior of physical activity among 9- to
13-year-olds by delivering messages through mass media,
school and community promotions. The VerbTM campaign,
as it was called, demonstrated that by using traditional
marketing approaches, a coordinated campaign with a
specific message to encourage healthy choices can have a
positive impact on awareness and behaviors. During the
campaign, youth awareness of the brand increased from
66 to 73%. The study recommendations call for a multiyear
commitment to branding and assert that the messages be
appealing to audiences to motivate behavior change
(Asbury, Wong, Price, & Nolin, 2008; Banspach, 2008).
The results of the VerbTM campaign also speculated that a
comprehensive campaign may be too resource intensive for
local communities to implement on their own (Asbury,
Wong, Price, & Nolin, 2008).
A second aim of our study was to assess the strength
of the environmental and policy changes implemented in
three of the six settings: Elementary schools, child care
programs, and afterschool programs. The Let’s Go! model
is a community-based approach, reaching most community members through its media messages and encouraging its voluntary partners to determine their own
priorities for change. Economos et al. (2007) found that
an intensive multifaceted approach involving schools,
families, the community, and the engagement of medical
providers in Somerville, Massachusetts, was effective in
slowing the rate of increase of overweight and obese children. The authors report ‘‘a decrease in BMI z-score by
.1005 (p ¼ .001, 95% confidence interval) among study
participants compared with children in control communities after controlling for covariates’’ (Economos et.al,
2007, p. 1325). However, the Somerville experiment
was conducted in a community with which it had an
existing relationship, and its findings cautioned that
future interventions would need ‘‘to establish a method
of collaboration to replicate the intervention’’ (Economos
et al., 2007, p. 1334).
The studies just described provide insight on
specific interventions and approaches with individuals
in controlled research-based settings. Evidence is lacking
on approaches that can be implemented and sustained
at the community level. It is clear from the literature
that prevention strategies need to involve populationbased interventions that target the places where people
spend time, and they should be practical to implement
and enforce. In this study, we analyze the depth and
scope of environmental changes implemented by partners in this community-based project and the contribution to changes in knowledge and adoption of healthy
behaviors.
1011
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Rogers et al.
Method
Study Design
The study was designed to document changes in healthy
behaviors as well as changes in policies and environments
that support the healthy behaviors among participants
from 2007 through 2011. Specifically, we measured awareness, knowledge, and healthy behaviors of adults and their
children in the 12 municipalities and also tracked the
extent of the program implementation at the participating
elementary schools, child care programs, and afterschool
programs. We did not conduct similar evaluations in the
health care, community, or workplace settings owing to
limited resources during the demonstration project. The
study used a quasi-experimental design that compared
measures before, during, and after program implementation (Shadish, Cook, & Campbell, 2002). We did not use a
comparison or control community group. A telephone
survey conducted with a cross section of area parents, randomly selected at three points in time, assessed child behaviors as well as parent awareness and knowledge of the
Let’s Go! program and the 5-2-1-0 message. Setting specific
measures gauged the implementation of the program strategies at each participating site. Maine Medical Center’s
Institutional Review Board for the protection of human
subjects approved all survey instruments and protocols
prior to administration and granted waivers of informed
consent.
Participants
The participants in the project included staff, patrons, and
their families at the participating sites from the six settings
of interest: Child care programs, schools, afterschool programs, community sites, health care practices, and
worksites in the 12 communities including and surrounding Portland, Maine, the locus of business for the founding
partners. The communities included Cape Elizabeth,
Cumberland, Gorham, Falmouth, Freeport, North
Yarmouth, Portland, Scarborough, South Portland,
Westbrook, Windham, and Yarmouth. These communities
account for 209,000 of the state’s 1.3 million residents,
with 49,000 children 19 years of age. Per capita income
for the region in 2010 was $32,395, with 11% of households living below the federal poverty levels; 91% identify
as White, 3% as Black or African American, and 3% as
Asian (U.S. Census Bureau, 2010). Program media covered
the entire population in the region, and all sites within the
six priority settings were invited to participate in the
program.
At the end of the five years, site involvement in the
demonstration project grew from no participation prior to
the project to include 56 of the 70 eligible schools educating 23,000 students, 34 child care programs caring for
1,400 children, 28 of 33 area afterschool sites engaging
1,800 students, 29 of 62 health care practices, seven of
the region’s largest employers, and community organizations from each of the 12 municipalities.
Let’s Go! Program Description
The Let’s Go! program consists of two components: A
communications campaign and community-based interventions in six settings. A staff of eight public health professionals, five full-time and three part-time, managed the
design, implementation, and evaluation of the multi-faceted project. They supported the demonstration project
as advisers to the participating sites in the Portland region.
Communications and Messaging Campaign
Throughout the 5-year demonstration project, Let’s Go!’s
marketing firm executed a comprehensive media campaign
to increase awareness of the 5-2-1-0 message among children and their families with advertisements broadcast on
television and spread through more targeted local marketing approaches such as on signs wrapped on the outside of
City of Portland buses, in short videos aired in movie theaters before the feature presentation, on web-banner advertisements on local news station Web sites, on signs in
sports arenas, and through a multi-page program Web
site. Television messages promoting the 5-2-1-0 message
and the individual healthy lifestyle behaviors ran on the
major television-network stations throughout the life of
the demonstration project. The broadcast media spots
used community members to encourage families and children to eat fruits and vegetables, to get outside and be
active together, to drink water, and to prepare healthy
meals from low cost options such as frozen and canned
vegetables. Local communications included posters and
storyboards used in StoryWalksTM for local youth events.
In addition, the Let’s Go! mascot named Redy, a large red
costumed character, made appearances on request at local
events to promote healthy lifestyles.
Community-Based Interventions
Concurrent with the media campaign, Let’s Go! staff
worked with area partners to implement 10 strategies in
the six priority settings, with a special focus on schools,
child care programs, and afterschool programs. These partners volunteered to act as local champions to facilitate
implementation of the program at their own site either in
a school, an early child care program, or an afterschool
15 grants
Number of mini-grants
Note: aA ¼ Administrators; T ¼ Teachers; P ¼ Parents; V ¼ Volunteers; SHC ¼ School Health Coordinators.
b
Child care programs did not implement the strategy to work with school nutrition programs.
c
Health care practices used 5-2-1-0 healthy habits materials and did not use the 10 strategies that were more appropriate for schools, child care programs, and afterschool programs.
d
5210 Goes to child care toolkit.
e
5210 Goes to school toolkit.
f
5210 Goes after school toolkit.
g
TA ¼ technical assistance; PM ¼ performance monitoring; SV ¼ site visits; S ¼ symposium; NDW ¼ nutrition director workgroup; W ¼ webinar for information sharing; E ¼ evaluation.
Monitoring
TA, PM academic detailing
0
0
TA, SV, PM, E
TA, SV, PM, E
34 grants
Let’s Go! supportg
TA, SV, PM, S, NDW, W, E
Toolkit , posters, handouts
Promotion/outreach materials
130 grants
By site
Designed by each site
Toolkit, posters, handouts
Toolkit , posters, handouts
Toolkit , posters, handouts
f
All 10
All 10
e
d
nutrition directors
9 of 10b
Strategies
Owner, A,T,P
Project champions and team
N/Ac
medical staff
Practice managers,
A,T,P, aides
Licensed child care programs
Program component
Table I. Let’s Go! Program Implementation Components by Setting
Schools
Let’s Go! staff introduced the program to local schools by
first identifying a staff member, called a Let’s Go!
Champion, who was interested in leading the work, and
then providing that person with a toolkit, guidance, and
support on how to implement the 10 strategies. Let’s Go!
recommends that the schools create teams to set local priorities, develop a work plan, and share the implementation
tasks. The two 5-2-1-0 Goes to School toolkits, one for the
elementary level and another for middle and high school
levels, provided schools with guidance on how to create a
team, how to conduct assessments of school supports of
healthy eating and physical activity, and how to implement
activities that support the 5-2-1-0 messages. The toolkits
also contained examples of school policies that could support the 5-2-1-0 behaviors. In addition, Let’s Go! staff gave
the school teams marketing materials, newsletters, and
convened an annual symposium for peer-to-peer sharing
and networking. Throughout the five years, a limited
number of small grants up to $2,500 were given to schools
through a competitive application process.
In addition to the school-based teams, Let’s Go! facilitated a workgroup for the school nutrition directors to
help them offer healthier options in their school lunch
programs. The members of the group worked together to
identify their priorities, to share ideas for implementation,
Elementary schools
The strategies and intervention approaches were adapted to
each setting, tailoring toolkits, handouts, and other materials for the specific audience. See Table I.
A,T,P, SHC, nurses,
Afterschool programs
Health care practices
1. encourage healthy choices for snacks and
celebrations;
2. participate in local, state, or national initiatives
that promote physical activity and healthy eating;
3. include community organizations in wellness
promotion;
4. involve and educate families in initiatives that
promote physical activity and healthy eating;
5. encourage water and low fat milk instead of
sugar-sweetened drinks;
6. discourage the use of food as a reward and use
physical activity as a reward;
7. incorporate physical activity into the school day;
8. develop a 5-2-1-0-friendly staff wellness program;
9. collaborate with School Nutrition Program; and
10. implement or strengthen a wellness policy that
supports the 5-2-1-0 strategies.
membersa
Community sites
program. The 10 strategies promoted in local sites were as
follows:
A,V, site participants
Impact of Let’s Go! 5-2-1-0
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Rogers et al.
and met periodically to discuss their progress on implementing changes.
Child Care Programs
The Let’s Go! child care program site-based work replicated
the school intervention by identifying local champions,
sharing materials and 5-2-1-0 Goes to Child Care toolkits,
and providing guidance on the implementation of the strategies to support healthy eating and physical activity. In
addition, all materials were adapted for use with infants
and children from birth through age two. Like the school
effort, Let’s Go! granted small amounts of funding to some
sites. In addition to the site-based work, program staff
worked with state licensing and training agencies to include the 5-2-1-0 message in their curriculum and materials used to train and certify licensed child care programs.
Moreover, the United Way of Greater Portland also required child care programs to adopt 5-2-1-0 strategies as
program policy as a condition of receiving agency funding.
Afterschool Programs
Similar to the school and child care program site-based
work, Let’s Go! promoted the 5-2-1-0 messages and the
10 environmental change strategies to increase healthy
eating and physical activity in the area afterschool programs. Let’s Go! provided the programs with a 5-2-1-0
Goes After School toolkit and technical assistance. The
afterschool setting Let’s Go! interventions reinforced the
5-2-1-0 message that the children were seeing in their
schools.
Health Care Practices
The Let’s Go! health care intervention was built on the
earlier Maine Youth Overweight Collaborative effort that
encouraged providers to reinforce the 5-2-1-0 messages
and support healthy choices (Polacsek et al., 2009).
Including health care providers added credibility to the
demonstration project and helped reinforce the link between the recommended behaviors and maintaining good
health. Using the Let’s Go! Health Care toolkit, providers
were encouraged to take three steps: (1) hang a 5-2-1-0
poster in the waiting room to share the message, (2) weigh
and measure patients accurately and compute body mass
index and weight status, and (3) hold conversations with
patients and families about healthy habits and weightrelated issues.
Worksites
When the project began, Let’s Go! worked with the seven
founding business leaders to introduce the 5-2-1-0 concept
to their employees in an effort to support the messages that
families were seeing in the community. As the program
grew and the effort concentrated on the places where children could be reached directly, the Let’s Go! worksite intervention evolved into a set of resources and tools housed
on the program Web site for use by interested employers.
Let’s Go! furnished local worksite champions with newsletters, posters, and materials developed for the other settings, as requested.
Community Sites
In addition to the media and outreach efforts in the 12
communities, Let’s Go! also provided a total of 15 small
grants, ranging from $1,500 to $10,000 through a competitive application process, to community organizations and
municipalities to seed local projects. During the five years,
community grantee organizations improved local trails;
added way-finding signs for biking, hiking, and skiing
trails; increased access to drinking water; sponsored a cultural dance program for children of immigrants; introduced
snowshoeing to children; and created an intervention for
Sunday school programs. Three child care centers shared
the largest grant award to fund new equipment for preparing meals from scratch as well as to increase options for
physical activity.
Measures
Awareness, Knowledge, and Behavior Changes
To measure awareness, knowledge, and behaviors related
to the 5-2-1-0 message, we conducted telephone interviews
with parents in 2007, in 2009 at project mid-course, and
in 2011 at the end of the five-year demonstration. Eight
hundred parents of children, ages newborn to 18 years,
living in the Let’s Go! Greater Portland communities
were randomly selected for each set of interviews. Each
survey wave had a sampling error of 3.5% at the 95%
confidence level, and sampling response rates using the
AAPOR RR3 calculations were 24% for 2007, 20% for
2009, and 26% for 2011 (AAPOR, 2011).
The questionnaire was tested with 10 respondents before full administration, and none of them raised any problems with the questions. Respondents were screened for
current place of residence, having one or more children
under the age of 18, living in the household at least 7
months of the year, and not be employed or have any
member of their immediate family who is employed in
the fields of advertising, market research, or journalism.
Interviews in each survey wave lasted 18 min on average.
In 2007, the survey sampling followed a stratified approach to interview a similar number of parents in each of
the 12 participating municipalities. In 2009 and 2011, the
samples were selected from the pooled 12-town region.
Impact of Let’s Go! 5-2-1-0
The final datasets used in the analyses were weighted to
represent the proportion of households by income levels
for each municipality to allow comparison among the three
waves.
The survey instrument covered six domains and 89
items in 2007, and 79 items in 2009 and 2011, including
parent knowledge of the 5-2-1-0 recommendations, parent
behaviors, child behaviors, awareness of and receptivity to
program communications, future intentions to change behaviors, and family demographics. We removed questions
from 2007 to 2009, to shorten survey length. The behavioral questions were adapted from the U.S. CDC’s Youth
Risk Behavior Survey (Centers for Disease Control and
Prevention [CDC], 2007) and the Behavioral Risk Factor
Surveillance Survey (CDC, 2007), and the awareness questions followed standard recall and awareness interrogatories used in measurements of advertising effectiveness
(Zielske & Henry, 1980).
Environmental and Policy Supports
Changes in environmental and policy supports were assessed directly with site-based partners. We developed surveys to measure the extent of implementation of the 10
recommended Let’s Go! strategies in the three settings with
the greatest numbers of participating sites: Elementary
schools, child care programs, and afterschool programs.
We did not develop comparable surveys for participating
community organizations, worksites, or health care
practices.
Champions in schools, child care programs, and
afterschool programs completed implementation surveys
during the months of May and June each year. The
survey instrument covered four domains of questions:
Team supports, community involvement, implementation
of the 10 strategies, and formal policies supporting 5-2-1-0
strategies. The three surveys varied in length: The elementary school survey contained 50 questions; the child care
provider survey had 30 questions; and the afterschool
program survey included 26 questions. The respondents
reported on their site experience with implementation by
responding to one of six categories: Not implemented, in the
planning stage, implemented in some classrooms (programs),
implemented in most classrooms (programs), implemented
school (program) wide, implemented school (program)
wide in previous years and continuing to implement.
Respondents were encouraged to review responses with
colleagues active in the work for site verification.
Response rates among participating sites for the 20102011 program year were as follows: Child care setting
(94%; n ¼ 16); elementary schools (73%; n ¼ 29); and
afterschool programs (88%; n ¼ 15).
Overview of the Analysis
To demonstrate the impact of the Let’s Go! intervention,
we compared key variables across the three waves of parent
surveys. We analyzed changes in parent awareness and
knowledge of the program and the 5-2-1-0 message, as
well as reports of their child’s behaviors. Specifically, we
analyzed parent awareness of the Let’s Go! media messages, self-reported exposure to the Let’s Go! and 5-2-1-0
messages in different settings, parent understanding of
each of the numbers in the 5-2-1-0 mnemonic, knowledge
of the four 5-2-1-0 health behaviors, and adherence to
those recommendations. The comparisons were conducted
using the Cochran–Mantel–Haenszel linear-by-linear association chi-squared test to examine differences among the
cross-sectional survey data from three points in time.
Analysis procedures were performed using SPSS version
20 and SUDAAN version 10.0.1, software designed to
handle complex sample designs. In addition, we used the
2011 implementation survey findings from the three settings to assess the extent of the implementation of the 10
Let’s Go! strategies at the end of the demonstration project.
Results
Participant Characteristics
In the 2011 parent survey, respondents were 67% female,
50% under the age of 45, 44% college graduates, and 37%
with household incomes of <$50,000. The respondents’
children, described in the survey responses, had a mean
age of 11.3 years (SD ¼ 4.7). The respondents to the first
and second survey waves shared similar demographics. The
mix of survey respondents was similar to the regional
census described earlier in educational attainment level,
family income, and age, but had a higher proportion of
females represented, 67%, compared with 52% in the
population.
Impact of the Multi-Level Intervention on
Awareness and Health Behaviors
The analysis of the parent-survey data shows statistically
significant increases in the proportion of parents reporting
awareness of Let’s Go! and the 5-2-1-0 message, knowledge
of the four 5-2-1-0 recommendations, and child adherence
with two of the 5-2-1-0 healthy behaviors over the five-year
program. The survey findings showed improvements in two
of the four behaviors: Parent-reported child adherence to
eating five or more servings of fruits and vegetables each
day and limiting consumption of sugary drinks each day.
See Table II. Overall, 31%, 95% CI [25, 36], of parents
reported that their child met at least three of the four
1015
1016
Rogers et al.
Table II. Changes in Parent Awareness of Program Messaging and in Child’s Behaviors
Survey 1
2007
N ¼ 801%, 95% CI
Survey 2
2009
N ¼ 800%, 95% CI
Survey 3
2011
N ¼ 802%, 95% CI
X2a
p-value
10 [7, 12]
45 [41, 50]
47 [43, 51]
13.12
<.001
14 [11, 16]
43 [39, 47]
55 [51, 59]
36.35
<.001
Correctly identify four healthy behaviors
41 [37, 45]
42 [38, 46]
47 [43, 51]
5.96
.015
Child adherence to eat five fruits and vegetables dailyb
Child adherence to limit recreational screen time
18 [15, 21]
41 [37, 45]
22 [19, 25]
44 [41, 48]
26 [23, 30]
45 [40, 49]
15.91
2.35
<.001
.125
61 [57, 65]
62 [58, 66]
60 [55, 64]
.56
.456
63 [59,67]
66 [61, 70]
69 [65, 73]
6.42
.011
Measure
Have you ever heard of Let’s Go! a health promotion
campaign in your area?
Have you ever heard a health message using the phrase
5-2-1-0?
to <2 hrc
Child adherence to engage in at least 1 hr of physical
activity
Child adherence to limit sugary beverages to <1 per day
Note: CI ¼ Confidence interval. Survey 1 is April–May; Survey 2 is May to July; Survey 3 is April to June.
a
Cochran–Mantel–Haenszel w2 test.
b
Consumption of five fruits and vegetables does not include consumption of fruit juice.
c
Combined percentage of child’s television viewing and other screen time behaviors.
recommendations in 2011. Parents reported favorable impressions to a description of the program in 2011; the
majority of parents, 73%, 95% CI [69, 77], reported
the program as ‘‘very positive’’ on a 5-point Likert scale;
the question was not asked in 2007.
The survey interviewers asked parents whether they
had seen or heard the Let’s Go! or 5-2-1-0 messages
using a prompted list of settings. Among parent respondents in 2011, 59%, 95% CI [53, 65], recalled seeing messages on television, 45%, 95% CI [39, 51], at school, 40%,
95% CI [34, 46], in a doctor’s office, 34%, 95% CI [28,
39], in materials sent home from school, and 18%, 95% CI
[13, 23], at work. The affirmative response of exposure in
each setting was counted for each respondent to create a
variable that described the total number of reported exposures to the messaging. Three categories of message exposure in multiple settings were created: ‘‘0,’’ ‘‘1–2’’ settings,
and ‘‘3 or more’’ settings. Results indicated a positive association between program and message awareness and
message exposure in multiple settings. Moreover, applying
the same test for trends, parents with higher message exposures were more likely to identify correctly each of the
specific 5-2-1-0 recommendations. See Table III.
Parent intentions to make changes ‘‘in the next six
months’’ to support their child’s healthy choices showed
no significant differences over the three survey waves. In
2011, 41%, 95% CI [37, 45], of parents reported that they
were likely to make changes to increase their child’s physical activity; 40%, 95% CI [36, 44], reported intentions to
make future changes to encourage their child’s consumption of fruits and vegetables; and 20%, 95% CI [17, 23],
reported intentions of future changes to encourage limits
on their child’s sugary drinks.
Implementation of the Let’s Go! Strategies
by Setting
The site-based implementation survey results show widespread implementation of the 10 Let’s Go! strategies in
child care programs, elementary schools, and afterschool
programs. Most of the sites in the three settings reported
implementation of the 5-2-1-0 strategies in most or all of
their classrooms by 2011. See Table IV. The three most
commonly implemented strategies were encouraging
healthy choices for snacks, encouraging drinking water,
and increasing physical activity during the day. Limiting
recreational screen time and strengthening or adopting
wellness policies were the least commonly implemented.
Discussion
The findings from this 5-year demonstration project suggest that parent exposure to an evidence-based community-level intervention bolstered by a coordinated
messaging campaign was associated with higher levels of
parent knowledge and greater prevalence of child health
behaviors necessary to prevent childhood obesity in a community. Over the same time period that Let’s Go! was
promoting the 5-2-1-0 message, parents reported positive
reactions, and greater awareness for the specific program
and the 5-2-1-0 message. These findings suggest that it is
possible for a community to implement a multiyear branding campaign aimed at behavior change that is appealing
Impact of Let’s Go! 5-2-1-0
Table III. Percentage of Parents Aware of Program Messages by Numbers of Reported Exposures, 2011
Number of reported settings of exposure
Zero (n ¼ 137),
% 95% CI
1–2 (n ¼ 106),
% 95% CI
Parents reporting awareness of Let’s
Go! or 5-2-1-0
34 [28, 40]
64 [55, 73]
85 [80, 90]
19.50
<.001
Parents correctly identifying all four
39 [33, 44]
51 [42, 61]
58 [51, 65]
43.15
<.001
Measure
3 (n ¼ 198),
% 95% CI
X2a
p value
5-2-1-0 recommendations
Note: CI ¼ Confidence interval. Table includes only parents with any reported message awareness, n ¼ 441. The responses do not include parents reporting no awareness of
the messaging. Total survey sample size is N ¼ 802.
a
Cochran–Mantel–Haenszel, a linear-by-linear association w2 test.
Table IV. Percentage of Sites Implementing the Let’s Go! Strategies in Most or All Classrooms, 2011
Child care programs
(n ¼ 16) %
Elementary schools
(n ¼ 29) %
Afterschool programs
(n ¼ 15) %
100
69
100
81
59
87
Encourage water
100
69
87
Encourage low or no fat milk
100
66
13
Let’s Go! strategy
Healthy eating
Encourage healthy choices for snacks
Encourage healthy celebrations
Discourage the use of food as a reward
Collaborate with the school lunch program
Active living
100
Not measured
62
80
66
33
Limit recreational screen time to <2 h/day
56
45
47
Increase physical activity during the day
94
72
100
Changes to promote sustainability
Implement or strengthen the wellness policy
38
55
Include community organizations to promote healthy living
38
41
Not measured
73
Note: Survey administered to local champions in April–May 2011. Reported percentages are not adjusted for non-responses.
and memorable, a concern voiced in the discussion of The
VerbTM (Asbury, Wong, Price, & Nolin, 2008). The sizeable improvement in awareness, however, is coupled with a
much smaller improvement over the same time period for
two of the four behaviors. This finding is a reminder of the
complex set of influences that determine behavior and the
psycho-social supports that may be needed to bring about
behavior change in individuals. Awareness and knowledge
of healthy behaviors along with supportive environments
are some of the components that lead to behavior change,
in conjunction with other motivating factors (Atkins &
Michie, 2013).
Furthermore, this demonstration project describes
how volunteers in schools, child care programs, and
afterschool programs may implement site-based programs
to promote healthy eating and physical activity when
allowed to choose local priorities from a list of evidencebased strategies and when given consistent easy to understand messages. Adapting community-level interventions
to the unique circumstances of local settings is an important feature of effective interventions and increases community support for the intervention (McLaren, Ghali,
Lorenzetti & Rock, 2007). The Let’s Go! network of sitebased volunteers serves as an extension of traditional
health interventions, creating an important intersectoral
approach that is far more effective than the health sector
addressing a public health issue alone (Gilson, Doherty,
Loewenson, & Francis, 2007). This study further reinforces the importance of building on existing community
relationships as a viable approach to establish the partnerships essential for successful and sustained communitybased obesity prevention interventions as called for by
Economos et al. (2007) in the Shape Up Somerville project.
However, the findings also show that while community
partners implemented widespread changes to local environments, few reported having site-based policies that
would codify and sustain the improved environments
into the future.
1017
1018
Rogers et al.
The study has several limitations of note. Parent responses in the telephone surveys about their child’s behaviors are subject to limitations in parent knowledge, and
may be influenced by a parent’s tendency to provide a
socially desirable response. Our analysis focused on the
differences in awareness and behaviors rather than the absolute results and so attempted to mitigate self-report and
social desirability bias. Future research would be improved
by using child reported behavior surveys, such as those
administered in schools by state health departments, by
using site-based observations of child behaviors, and by
measuring child body mass index as the ultimate health
outcomes. We are currently working with local and state
education and health care professionals to identify the appropriateness of using existing longitudinal datasets of
child behaviors, as well as height and weight measures,
to quantify any changes in health behaviors and weight
status.
In addition, the site-based surveys documented implementation at each site and the total populations frequenting each site, but the study did not measure the actual
reach of participants impacted by the community-based
program components. The study methods did not include
a structured observational assessment to verify the sitereported outcomes. This will be important in future studies
to check for consistency in reporting local outcomes.
Finally, it is important to acknowledge that, as with most
community-based programs focusing on important local
issues, there were other child-centered healthy eating and
physical activity efforts active in the region and state at the
same time, making it difficult to attribute outcomes to a
single program. Some of the programs included the
Coordinated School Health Program, the Maine Nutrition
Network, and WinterKids. Thus, it was not feasible to use a
control or comparison region to isolate program effects.
Although this may be a limitation in measuring specific
impact, it is also an opportunity for future research to explore the collective impact of regional groups working together to address common issues (Kania & Kramer, 2011).
Recognizing the complexities and interconnections of
the factors at play in preventing obesity, community-based
programs and studies should focus on three components
for future work: Engaging parents, strengthening policies in
local sites, and expanding partnerships to harness collective impact. Parents and guardians play important roles in
teaching and reinforcing healthy habits with their children.
Future programs would benefit from supporting parents in
creating and maintaining healthy home environments, so
health messages seen and heard at school and in the community are then reinforced culturally and socially in the
home environment.
In addition, building on the interest of local sites to
change environments, community-based programs have an
opportunity to develop and promote the adoption of model
policies addressing healthy eating and active living in
schools, child care, afterschool, health care, and other community sites to increase the possibility of sustaining and
preserving the environmental changes and reinforcement of
healthy habits. Community or regional partnerships like
Let’s Go!, with broader reach, may have more success in
building support for these policy changes than single sites
acting alone.
Finally, the Let’s Go! program was founded by a group
of area businesses that shared the same goal of reducing
obesity among area children. Their commitment and collaboration was the catalyst for program development, implementation, and ultimate community engagement in the
effort. Collective action by community leaders and organizations is a promising means to create community change
to address complex public health issues such as childhood
obesity.
In summary, a community-based awareness and environmental change approach to increase physical activity
and healthy eating that reaches families in multiple settings
was associated with improved parent understanding of
these behaviors as well as some child behavior changes.
Further, it shows that volunteers in schools, child care
programs, afterschool programs, health care practices,
community sites, and worksites make changes to their environments to support healthy eating and activity when
given simple tools and information to support their efforts.
A community-based multi-setting environmental change
program, reinforced with a memorable message, is a
viable foundation for mitigating the influences that lead
to childhood obesity.
Acknowledgments
The authors are thankful to the Maine Center for Disease
Control and Prevention; the Maine Department of
Education; the Coordinated School Health Program; the
Greater Portland Healthy Maine Partnerships; participating schools, child care centers, afterschool programs, and
health care practices; WinterKids; the Maine Nutrition
Network; and the Maine Chapter of the American
Academy of Pediatrics. We would like to thank Seth
Emont, PhD, of White Mountain Consulting, for his guidance on framing the study analysis, his thoughtful review,
and personal support throughout the demonstration project. We would like to thank two Portland, Maine, market
research firms for their contributions to the study: Critical
Insights for support with survey data collection, and
Impact of Let’s Go! 5-2-1-0
Market Decisions for advanced statistical analysis. We
also thank Kahsi Smith, PhD, of the Maine Medical
Center Research Institute for her wisdom and insight on
the writing process.
Funding
This work was supported by the American Academy of
Pediatrics; the Anthem Foundation; the United States
Department of Health and Human Services, Centers for
Disease Control and Prevention Communities Putting
Prevention to Work grant number 1U58DP002520-01;
the Convergence Partnership Fund of the Tides
Foundation; the Frances Hollis Brain Foundation;
Hannaford Brothers; Harvard Pilgrim Health Care
Foundation; the National Initiative for Children’s
Healthcare Quality; Jane’s Trust; Leonard C. & Mildred
F. Ferguson Foundation; Maine Health Access
Foundation; Maine Medical Center; MaineHealth; the
New Balance Foundation; the Rite Aid Foundation; the
Sam L. Cohen Foundation; the TD Charitable
Foundation; The Bingham Program; The Mattina R.
Proctor Foundation; the United Way of Greater Portland;
Unum; and the Walmart Foundation.
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